Case Management Of Ari At Phc Level

CASE MANAGEMENT OF ARI AT PHC LEVEL

Definition: ARI is an acute infection of less than 30 days duration of any part of the respiratory tract and related structures (from nose to alveoli). For middle ear infection - duration of acute infection is taken as 14 days or less

Classification Of ARI Acute upper respiratory tract infection (AURI) include the common cold, pharyngitis and otitis media. Acute lower respiratory tract infection (ALRI) include epiglottitis, laryngitis, bronchitis, bronchiolitis and pneumonia.

Respiratory system

PROBLEM STATEMENT ARI is responsible for about 30 - 50% of visit to health facility and for about 20 - 40% of hospital admission On an average children below 5 yr of age suffer about 5 episodes of ARI per year ARI is one of the major cause of death in under five children - 13% of inpatient death in Paediatric ward - 90% of ARI death are due to Pneumonia Burden of disease in terms of Daly's lost - is 25.5 million in which 24.8 million is due to ALRI, 2.74 lakh - AURI, 4.75 lakh - Otitis media

CLINICAL ASSESSMENT History: How old is the child? Is the child coughing ? for how long? Is the child eating/drinking well since the onset of present illness? Is the child excessively drowsy or difficult to wake? Did the child have convulsion? Did the mother notice irregular breathing? Any antecedent illness such as measles? Any other complaints?

PHYSICAL EXAMINATION Count the breath in one minute # Child must be calm # Expose the chest and abdomen # Count RR for 1 full minute # Repeat counting if RR is high or when in doubt # Fast breathing is present when the RR is : 60 0r more in a child < 2 months 50 or more in a child 2 - 12 months 40 or more in a child 12 months - 5 yrs

CHEST INDRAWING Definite inward motion of lower chest wall while breathing in Child should be observed lying flat in the bed or mother’s lap Intercostals and supraclavicular retraction in which only soft tissue goes in is not chest in drawing Child under 2 yrs may have mild chest in drawing Because of soft chest wall

Look and listen for stridor: Harsh noise when breathing in (due to narrowing of larynx, trachea, or epiglottis) Look for wheeze: A child with wheeze makes soft whistling noise or shows signs that breathing out is difficult. See if the child is abnormally sleepy or difficult to wake Feel for fever or hypothermia Check for severe malnutrition Cyanosis

CLASSIFICATION OF ILLNESS A: child aged 2 months up to 5 years 1. Very severe disease 2. Severe pneumonia 3. Pneumonia 4. No pneumonia

VERE SEVERE DISEASE Signs: not able to drink Convulsion Abnormally sleepy Stridor in calm child Severe malnutrition Treatment: refer urgently to hospital Give first dose of antibiotics Treat fever / wheezing if present If cerebral malaria is possible, give an anti malarial.

SEVERE PNEUMONIA Signs:

Chest indrawing Fast breathing + /Nasal flaring Grunting Cyanosis

Treatment : Refer urgently to hospital Give first dose of antibiotic Treat fever / wheeze if (+)

PNEUMONIA Signs : fast breathing and no chest in drawing Treatment : Advice mother to give home care Give an antibiotic Treat fever / wheeze if (+) Advice mother to review in 2 days or earlier if the child worsens During review : Worse - refer to hospital Same - change antibiotic or refer Improving - finish 5 days of antibiotic

NO PNEUMONIA No chest in drawing & no fast breathing Treatment : - If coughing > 30 days refer for assessment - Assess & treat ear problem or sore throat if (+) - Advice mother to give home care - Treat fever / wheezing (+)

B.CLASSIFYING THE ILLNESS OF INFANT VERY SEVERE DISEASE - Stopped feeding well - Convulsions - Abnormally sleepy - Stridor, wheeze - Fever / hypothermia TREATMENT: - Refer urgently to hospital - Keep infant warm - Give 1ST Dose of antibiotic

2. SEVERE PNEUMONIA - Severe chest in drawing or fast breathing TREATMENT: - Refer urgently to hospital - Keep infant warm - Give 1st dose of antibiotic 3. NO PNEUMONIA - No chest in drawing or fast breathing TREATMENT : - Advice mother to give home care

MEDICAL TREATMENT Treatment for children (2 months- 5 yrs) pneumonia Age / weight

< 2months

Paediatric tablet: Sulphamethoxazole 100 mg & Trimethoprim 20mg 1 tab bd

2 - 12 months 2 tab bd 1- 5 yrs 3 tab bd

Syrup (5ml) Sulphamethoxazole 200mg & Trimethoprim 40mg ½ Spoon bd 1 spoon bd 1 ½ spoon bd

SEVERE PNEUMONIA A. First 48hrs - Benzyl penicillin 50,000iu/kg/dose 6 hourly IM - Or Ampicillin 50mg/kg/dose or Chloramphenicol 25mg /kg/dose 6 hourly IM B. If condition improves, then for next 3 days - Give procaine penicillin 50,000 iu/kg OD IM - Or Ampicillin 50mg/kg/dose or Chloramphenicol 25mg/kg/dose orally 6 hourly If no improvement then for next 48hrs - Change antibiotic

Cont. C. Provide symptomatic treatment for fever & wheezing if required D. Monitor fluid & food intake E. Advice mother on home management on discharge

VERY SEVERE DISEASE Should be treated in health facility with provision for Oxygen therapy & intensive monitoring O - Chloramphenicol IM is the drug of choice. Treat for 48hrs - If condition improves start orally. - If worsens switch to Cloxacillin & Gentamycin. -

PNEUMONIA IN YOUNG INFANTS ANTIBIOTIC

DOSE

FREQUENCY AGE < 7 Days 7 days 2 Months 50,000 IU/KG 12 Hrly 6 Hrly

Inj. Benzyl Penicillin or Inj. Ampicillin & 50 mg / kg /

12 Hrly

8 Hrly

Inj.Gentamycin

12 Hrly

8 Hrly

2.5 mg / kg

HOME CARE Advice mother - Feed the child during illness - Increase feeding after illness - Clear the nose if it interferes with feeding - Increase the fluid intake of the child - Advice to continue breast feeding - Soothe the throat and relieve the cough with safe remedy - Watch for signs of pneumonia

TREATMENT OF FEVER If fever is high > 39 c - Give paracetamol 6 hourly till temp drops < 39 c If fever is low - Advice mother to give more fluids - Keep the child lightly clothed In areas with falciparum Malaria - Start anti-malarials

TREATMENT OF WHEEZING 1st episode - Look for signs of respiratory distress If present Give rapidly acting bronchodilators

If Not present Give oral bronchodilators

Recurrent episode - Give rapidly acting bronchodilator

EAR PROBLEM Signs

Tender swelling behind the ear

Classify as Mastoiditis

Treatment Referal Antibiotic treat fever & pain

Pus from ear < 2wk Ear pain Red ear drum Acute infection

Pus from ear > 2wk

Antibiotic Dry the ear by wicking

Dry the ear

Chronic infection

Measures To Reduce Complication Of ARI -

Improve the nutrition of the child Reduction of air pollution Immunisation Early diagnosis & treatment Teaching the mother about the signs of pneumonia Promote breast feeding Training of health workers to identify the signs of pneumonia - Referral at the appropriate time

ARI CONTROL PROGRAMME - Was taken up as a pilot project in the country in the yr 1990 - Since 1992-1993 it is implemented as a part of CSSM programme Aim of the programme - Improving treatment practices in hospitals& health centres to reduce mortality rates due to pneumonia - To reduce the unnecessary use of antibiotics

REFERENCE National CSSM programme-integrated clinical skills course for physicians The management of ARI in children - practical guidelines for outpatient care Park’s textbook of preventive and social medicine

THANK YOU